Not all CKD patients prefer dialysis

Abstract

MedWire News: Patients approaching end-stage kidney disease are willing to trade considerable life expectancy to reduce the burden and restrictions imposed by dialysis, Australian researchers report.

They found that patients with stage 3-5 chronic kidney disease (CKD) were willing to forgo 7 months of life expectancy to reduce the number of required visits to hospital from four to three per week, and 15 months of life expectancy to decrease their travel restrictions from very restricted to somewhat restricted.

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Rachel Morton (University of Sydney) and colleagues explain that for every patient with CKD who undergoes renal-replacement therapy, there is one patient who undergoes conservative management of their disease.

The decision to start dialysis, rather than receive conservative care with dietary modifications, erythropoietin, and/or diuretics, involves an assessment of both the evidence-based outcomes for the population in question and the preferences of the individual patient, the researchers explain.

To determine the most important characteristics of dialysis and the trade-offs patients were willing to make in choosing dialysis instead of conservative care, Morton and team conducted a discrete choice experiment involving 105 adults (median age, 63 years) with stage 3-5 CKD (mean estimated glomerular filtration rate, 18.1 mL/min per 1.73 m2) from eight renal clinics in Australia.

They used the discrete choice method because it allows the quantification of patients' strengths of preferences for different treatment characteristics and the trade-offs involved.

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These treatment characteristics included life expectancy, number of visits to the hospital per week, ability to travel, time spent undergoing dialysis (ie, hours spent attached to a dialysis machine per treatment), time of day at which treatment occurred, availability of subsidized transport, and flexibility of the treatment schedule.

As reported in the Canadian Medical Association Journal, the odds for preferring dialysis to conservative care increased with increasing estimated life expectancy (odds ratio [OR]=1.84 per additional year of life).

The odds for preferring dialysis to conservative care also increased if subsidized transport for attending treatments and appointments was available (OR=1.55) and if patients were able to dialyze during the day or evening rather than during the day only (OR=8.95).

Patients were less likely to choose dialysis over conservative care if an increase in the number of visits to hospital was required (OR=0.70 per visit per week) or if there were restrictions on their ability to travel (OR=0.47 vs no restrictions).

Patient age, gender, type of health insurance, level of education, employment status, distance from home to the dialysis unit, size of household, income, stage of CKD, previous kidney transplant, and the opportunity to receive nocturnal dialysis did not significantly affect preferences

Morton and co-authors say their findings indicate that "dialysis should not be presumed to be the treatment of choice for all patients approaching end-stage kidney disease."

Because of this,"there needs to be effective policy and clinical pathways to support patients who choose not to undergo dialysis," they conclude.